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In 2002, GAO reported that the Centers for Medicare & Medicaid Services (CMS) needed to improve its communications with providers who deliver medical care to beneficiaries. GAO reported that 85 percent of the responses it received to 61 calls made to call centers operated by Medicare carriers--contractors that help manage the Medicare program--were incorrect or incomplete. GAO also found that CMS's primary oversight tools were insufficient to ensure accuracy in communication. GAO was asked whether call centers now provide correct and complete information to providers. GAO (1) reviewed carriers' effectiveness in providing correct and complete responses to policy-oriented telephone inquiries and CMS's efforts to improve communications with providers and (2) evaluated CMS's efforts to provide oversight of carrier call centers.

Only 4 percent of the responses GAO received in 300 test calls to 34 call centers were correct and complete. GAO posed four policy-oriented questions 75 times each to carrier call centers. The level of correct and complete responses for each individual billing question ranged from 1 to 5 percent. The majority of remaining responses were incorrect, or partially correct or incomplete. Several factors, including fragmented sources of information, confusing policy information, and difficulties in retaining the CSRs responding to calls appear to account for the lack of correct and complete answers. There are many call centers serving other industries that triage incoming calls by first identifying the nature of the call and then distributing it to the CSR who is best qualified to respond. Although CMS has not adopted this approach, it is currently implementing two other initiatives that may improve CSRs' access to information. However, neither initiative is specifically designed to support CSRs responding to policy-oriented questions. In addition, CMS's efforts to provide oversight of carrier call centers are inadequate. Although CMS requires carriers to monitor the performance of their call centers, the standards used and the technological resources available to evaluate performance do not allow carriers to thoroughly assess whether CSRs' responses are correct and complete. In addition, CMS's own monitoring efforts are too infrequent. CMS only performed one contractor performance evaluation related to carrier telephone services in fiscal year 2002 and none were performed in fiscal year 2003. Moreover, when performed, these evaluations did not provide sufficiently detailed information to assess CSRs' performance.

Recommendations for Executive Action

Status: Closed - Implemented

Comments: On September 10, 2004, CMS issued an instruction to its claims processing contractors to develop an inquiry triage process for telephone inquiries. This new process took effect at all carriers in January 2005. All of the carrier call centers must have at least two levels of customer service representatives dedicated to respond to provider inquiries. If the type of question is such that it requires in-depth research, such as a complex policy question, it must be referred to a new group of staff, Provider Relations Research Specialists (PRRS). The PRRS are trained to do the necessary research to provide a complete and accurate response to the inquiries. To do this, the PRRS have additional time to respond and the responses will usually be in writing.

Recommendation: In order to improve the accuracy and completeness of responses to policy-oriented inquiries from providers, the Administrator of CMS should take steps to ensure that all customer service representatives have the necessary tools to respond to such calls. Specifically, the Administrator should create a process to routinely screen and triage calls by routing complex policy-oriented questions to staff with the expertise to adequately address them.

Comments: In July 2005, CMS reported that it now routinely develops and issues job aids connected to program changes to its customer service representatives (CSR). These job aids provide an easy reference for CSRs to use in answering provider inquiries. The complex policy questions are triaged to Provider Relations Research Specialists who have the expertise to thoroughly research an inquiry and the time to provide a written response.

Recommendation: In order to improve the accuracy and completeness of responses to policy-oriented inquiries from providers, the Administrator of CMS should take steps to ensure that all customer service representatives have the necessary tools to respond to such calls. Specifically, the Administrator should develop clear and easily accessible policy-oriented materials to assist CSRs. The materials should be electronically searchable so that CSRs can expeditiously provide correct and complete responses to policy-oriented questions.

Comments: CMS reported in July 2005 that, in addition to the new required inquiry triage process to ensure that telephone inquiries are answered by staff with the appropriate expertise, it increased the number of calls that are monitored for quality measurement. Effective January 2005, five calls per month per customer service representative are monitored for accuracy, customer skills, and adherence to the privacy act. The current performance standard is 93 percent accuracy, an increase over the past standard of 90 percent. Over time, CMS plans to increase this standard. CMS did not provide new information in 2006 or 2007.

Recommendation: In order to improve the accuracy and completeness of responses to policy-oriented inquiries from providers, the Administrator of CMS should take steps to ensure that all CSRs have the necessary tools to respond to such calls. Specifically, the Administrator should establish an effective monitoring program for call centers to assess customer service representatives' performance. The program should include the development of specific performance standards that will allow CMS to thoroughly and routinely measure the correctness and completeness of information given by CSRs in response to policy-oriented questions.